Emergency peripartum hysterectomy (EPH) is a critical, life-saving surgical intervention performed as a last resort in the management of severe obstetric complications. It is most often indicated in cases of massive postpartum hemorrhage, uterine rupture, morbidly adherent placenta, or other causes of uncontrollable bleeding that occur during labor, at the time of delivery, or in the immediate postpartum period. The decision to perform EPH is usually made when all conservative medical and surgical measures have failed to control hemorrhage, and the procedure remains one of the most definitive methods of preventing maternal mortality in such life-threatening circumstances [1]. Globally, the incidence of EPH is relatively low, ranging approximately between 0.2 and 1.5 per 1,000 deliveries, but it remains a significant contributor to maternal morbidity and mortality, particularly in settings with limited access to advanced obstetric care [2]. The procedure is often associated with high-risk pregnancies and occurs more frequently in women with underlying risk factors such as advanced maternal age, multiparity, history of cesarean delivery, placenta previa, placenta accreta spectrum disorders, and other uterine abnormalities [3]. Obstetric hemorrhage is widely recognized as the leading indication for EPH, with uterine atony and placenta-related complications accounting for the majority of cases. Uterine rupture, either spontaneous or related to prior surgical scars, further contributes to the need for this radical intervention, and prompt recognition and management of these conditions are essential to prevent life-threatening outcomes [4]. Additional risk factors, including multiple gestations, polyhydramnios, and other pregnancy complications, can exacerbate the likelihood of severe hemorrhage requiring hysterectomy [5]. Management of patients requiring EPH is often complex and resource-intensive. Immediate resuscitation, including rapid intravenous fluid replacement, blood transfusion, and correction of coagulopathy, is critical to stabilize the patient before and during surgery [6]. Surgical intervention itself can be technically challenging, particularly in cases of abnormal placentation or distorted pelvic anatomy, requiring experienced obstetric surgeons and a multidisciplinary approach. Postoperative care demands close monitoring in intensive care settings to manage potential complications such as hemorrhagic shock, infection, thromboembolic events, and organ dysfunction [7]. Furthermore, psychological support and counseling are essential components of comprehensive care, as women may face long-term reproductive, hormonal, and emotional consequences following hysterectomy [8]. In low-resource settings, these challenges are amplified by limitations in healthcare infrastructure, delayed referrals, insufficient skilled personnel, and inadequate access to blood products and emergency surgical facilities [9]. Preventive strategies, including early identification of high-risk pregnancies, meticulous antenatal monitoring, timely referral to tertiary centers, and preparedness for obstetric emergencies, are essential in reducing the incidence and improving outcomes of EPH [10]. Despite advancements in obstetric management and increasing awareness of risk factors, emergency peripartum hysterectomy remains a crucial measure in safeguarding maternal life when conservative measures fail. Understanding the incidence, underlying causes, treatment challenges, and risk factors for EPH is vital for developing evidence-based strategies to reduce maternal morbidity and mortality, guide clinical decision-making, and enhance patient counseling. This study aims to evaluate the incidence and identify the risk factors associated with emergency peripartum hysterectomy in a tertiary care hospital.

This was a retrospective observational study conducted at the Department of Obstetrics and Gynaecology, BSMMU and Dhaka Medical College Hospital, Dhaka, Bangladesh from January 2007 December 2009 a high-volume tertiary referral center. Ethical approval was obtained from the Institutional Review Board, and patient confidentiality was strictly maintained throughout the study. A total of 54 EPH cases were identified out of 24,000 deliveries, providing an overall incidence of 2.25 per 1,000 deliveries (0.23%).

Inclusion and Exclusion Criteria

Inclusion Criteria:

1. Women who underwent emergency peripartum hysterectomy (EPH) during or within 24 hours of delivery for life-threatening obstetric hemorrhage or related complications.
2. Patients delivered at the study hospital during the study period.
3. Complete medical records available for demographic, obstetric, surgical, and outcome variables.

Exclusion Criteria:

1. Women who underwent elective or planned hysterectomy for non-obstetric indications.
2. Cases with incomplete or missing medical records.
3. Hysterectomy performed beyond 24 hours postpartum unless directly linked to uncontrolled peripartum hemorrhage.
4. Patients with pre-existing gynecological malignancies requiring hysterectomy.

Data Collection

Data for this study were retrospectively extracted from hospital medical records, operative notes, and the electronic health information system using a structured data collection form. Demographic and obstetric information, including maternal age, parity, residence, and history of previous cesarean section, was recorded for all women undergoing emergency peripartum hysterectomy. Clinical presentation variables were documented, including mode of delivery, gestational age at delivery, and indications for cesarean section. Antenatal complications such as placenta previa, placenta accreta spectrum (PAS), pre-eclampsia/eclampsia, placental abruption, and multiple gestations were also captured. Intraoperative details, including the type of hysterectomy (subtotal versus total), operative time, estimated blood loss, units of packed red blood cells transfused, and intraoperative complications (bladder, ureteral, bowel, or vascular injuries, and re-laparotomy during the same admission), were meticulously recorded. Maternal outcomes were documented in terms of ICU admission, prolonged hospital stay (>7 days), febrile morbidity, wound infection, paralytic ileus, and maternal mortality. Neonatal outcomes, including live births, early neonatal deaths (≤7 days), stillbirths, and neonatal ICU admissions, were collected from delivery records and neonatal charts. Finally, key obstetric risk factors potentially associated with severe maternal morbidity, including previous cesarean section, PAS, placenta previa, uterine atony, and uterine rupture, were specifically identified and noted to enable both univariate and multivariate analysis. All data were anonymized to maintain patient confidentiality and cross-checked for consistency and accuracy by two independent researchers.

Statistical Analysis

Data were analyzed using SPSS v26.0. Continuous variables are presented as mean ± SD or median (IQR), and categorical variables as frequencies and percentages. Incidence of emergency peripartum hysterectomy was calculated per 1,000 deliveries and as a percentage. Associations between obstetric risk factors and severe maternal morbidity (ICU admission or death) were assessed using relative risk (RR) with 95% confidence intervals. Variables with p <0.1 in univariate analysis were included in a multivariate logistic regression model to identify independent predictors, reported as adjusted odds ratios (aOR) with 95% CI. A p-value <0.05 was considered statistically significant.

Table 1 presented the incidence of emergency peripartum hysterectomy (EPH) during the study period. Out of 24,000 deliveries, 54 women required EPH, corresponding to 2.25 per 1,000 deliveries or 0.23% of all deliveries. Although relatively rare, EPH remains a vital intervention for managing life-threatening obstetric complications. Table 2 summarized the baseline characteristics of the 54 women undergoing EPH. Maternal age ranged from ≤24 years (11.11%) to ≥40 years (14.81%), with a mean of 32.6±5.7 years. Parity distribution showed 12.96% primipara, 48.15% multipara, and 38.89% grand multipara. Most women (64.81%) resided in rural areas, and 61.11% had a history of previous cesarean section. These demographics help contextualize the population at risk for EPH. Table 3 detailed obstetric and clinical characteristics at presentation. Cesarean delivery accounted for 74.07% of cases, mainly due to prior cesarean (42.59%), malpresentation (11.11%), and failed labor progression (9.26%). Gestational age was 37–40 weeks in 70.37% of cases. Antenatal complications included placenta previa (22.22%), placenta accreta spectrum (PAS) (24.07%), pre-eclampsia/eclampsia (14.81%), placental abruption (11.11%), and multiple gestation (7.41%). Table 4 illustrated risk factors and surgical indications. PAS (24.07%), placenta previa (22.22%), uterine atony (27.78%), uterine rupture (11.11%), infection/sepsis (9.26%), and structural abnormalities (7.41%) were the main contributors to EPH. Table 5 described surgical details. Subtotal hysterectomy was performed in 66.67% and total hysterectomy in 33.33%. Mean operative time was 118±34 minutes, with estimated blood loss of 2150±780 mL and median transfusion of 6 units. Intraoperative complications were uncommon. Table 6 showed outcomes: 22.22% required ICU admission, 50% had prolonged hospital stay, febrile morbidity occurred in 27.78%, and there was one maternal death (1.85%). Neonatal outcomes included 90.74% live births, 5.56% early neonatal death, 16.67% stillbirth, and 14.81% NICU admission. Previous cesarean, placenta accreta spectrum and uterine rupture showed statistical significance (p=0.031, p=0.002 and p=0.041 respectively) (Table 7). Table 8 highlighted predictors of severe maternal morbidity. Univariate analysis showed significant associations with previous cesarean, PAS, and uterine rupture. Multivariate regression identified PAS (adjusted OR 5.12; p = 0.006) and previous cesarean (adjusted OR 2.84; p = 0.041) as independent predictors, emphasizing the importance of early recognition and careful management in high-risk pregnancies.

Table 1: Incidence of emergency peripartum hysterectomy

Table 2: Baseline demographic characteristics of women undergoing emergency peripartum hysterectomy (n = 54)

Table 3: Obstetric and clinical characteristics at presentation among women undergoing emergency peripartum hysterectomy

Table 4: Distribution of predisposing risk factors and primary surgical indications for emergency peripartum hysterectomy

Table 5: Intraoperative surgical details and perioperative parameters of emergency peripartum hysterectomy

Table 6: Maternal and neonatal outcomes following EPH

Table 7: Univariate association of major obstetric risk factors with severe maternal morbidity (ICU admission or death) in women undergoing emergency peripartum hysterectomy

Table 8: Multivariate logistic regression analysis of independent predictors of severe maternal morbidity following emergency peripartum hysterectomy

Emergency peripartum hysterectomy (EPH) represents a life-saving surgical intervention performed as a last resort to control catastrophic obstetric hemorrhage [11]. In our study, the incidence of emergency peripartum hysterectomy (EPH) was 2.25 per 1000 deliveries. This rate is higher than a previous study by Khanum et al., who reported those reported that the incidence of emergency peripartum hysterectomy (EPH) was 1.55 per 1000 deliveries [12]. Our figure therefore reflects the intermediate range, likely influenced by high cesarean section rates and variable access to antenatal risk detection. The mean maternal age in our cohort was 32.6 ± 5.7 years, with most patients between 25–34 years. This trend aligns with findings from other series, where EPH is more common among women in their third and fourth decades due to increased obstetric risks in these groups [13]. High parity was also notable, with 38.89% grand multipara, consistent with the established role of multiparity as a risk factor for hemorrhage and uterine rupture [14]. Moreover, a predominance of rural residence (64.81%) may indicate disparities in access to antenatal care, which has been noted similar in a previous study by Diab (2005), reinforcing prior cesarean delivery as a leading demographic determinant of EPH [15]. The majority of women (74.07%) underwent cesarean section, with previous cesarean being the most common indication (42.59%). Comparable findings were observed by Forna et al., where cesarean was the dominant delivery mode among EPH cases [16]. Most deliveries occurred at term (70.37%), similar to global patterns where EPH is not limited to preterm but occurs predominantly at term pregnancies [17]. Among antenatal complications, placenta previa (22.22%) and placenta accreta spectrum (24.07%) were most frequent, again mirroring global evidence that abnormal placentation constitutes a major risk for EPH [18]. In our series, uterine atony (27.78%), placenta accreta spectrum (24.07%), and placenta previa (22.22%) were the leading primary indications for hysterectomy. This distribution aligns with global reviews: Yamani (2003) presented in a review paper that uterine atony was the leading indication for hysterectomy, observed in 11 cases (64.7%; 9 without placenta previa and 2 with previa), followed by morbidly adherent placenta with previa in 6 cases (35.3%; including 1 complete placenta accreta and 5 partial adherent placenta) [1]. Our slightly higher proportion of atony resembles findings in South Asian studies, reflecting limited availability of uterotonic agents and delayed intervention. Uterine rupture (11.11%) also featured prominently, consistent with 2.4 per 1000 in those undergoing a trial for vaginal delivery reported by Kieser & Baskett (2002) [19]. Our study had the mean operative time of 118 minutes and average blood loss of 2,150 ± 780 mL. In the study of Hsu et al., the mean operative time for managing peripartum hemorrhage was approximately 150 minutes, ranging from 85 to 335 minutes, while the average estimated blood loss was 3,800 mL, with a range of 2,700 to 12,000 mL [20]. The maternal morbidity profile was significant, with 22.22% requiring ICU admission, 27.78% febrile morbidity, and 16.67% wound infections. One maternal death occurred (1.85%), which shows similarities with previous studies [2]. Neonatal outcomes showed 16.67% stillbirths and 5.56% early neonatal deaths, comparable to findings in similar low- and middle-income country (LMIC) settings, where emergency hysterectomy is often performed after catastrophic obstetric events [21]. In univariate analysis, previous cesarean section, placenta accreta spectrum, and uterine rupture significantly increased risk of severe maternal morbidity. Similar associations have been documented by Guise et al., where abnormal placentation and uterine rupture were strong predictors of maternal complications [22]. This supports the hypothesis that prior cesarean predisposes to PAS and rupture, creating a chain of risk culminating in hysterectomy. On multivariate regression, placenta accreta spectrum (OR 5.12) and previous cesarean section (OR 2.84) were independent predictors of severe maternal morbidity, while uterine rupture approached significance. These findings closely parallel x et al.’s meta-analysis, which concluded that prior cesarean and abnormal placentation are the strongest global predictors of EPH and poor outcomes [23]. The strength of association in our study underscores the urgent need to address rising cesarean rates, improve antenatal diagnosis of PAS, and ensure timely referral of high-risk pregnancies to tertiary centers.

This study has certain limitations. First, being a single-center retrospective analysis, the findings may not be generalizable to wider populations. Second, reliance on medical records introduced the possibility of incomplete documentation and recall bias. Third, the relatively small number of EPH cases limited statistical power for subgroup analyses. Finally, long-term maternal outcomes, including psychological impact and reproductive consequences, were not assessed. Despite these limitations, the study provides valuable insight into risk factors and outcomes of EPH.

Emergency peripartum hysterectomy, though infrequent, remains a critical life-saving intervention in obstetric emergencies. In our cohort, the incidence was substantially higher than rates reported in high-income settings, reflecting referral bias and systemic limitations. Placenta accreta spectrum and prior cesarean section emerged as the strongest independent predictors of severe maternal morbidity, underscoring the cumulative risks of rising cesarean rates. Optimizing antenatal surveillance for abnormal placentation, improving preparedness for high-risk deliveries, and adopting judicious cesarean practices are essential to mitigate this burden. Strengthening multidisciplinary management strategies is pivotal to improving maternal survival and reducing preventable complications.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

1. Yamani Zamzami TY. Indication of emergency peripartum hysterectomy: review of 17 cases. Archives of gynecology and obstetrics. 2003 Aug;268(3):131-5.
2. Kwee A, Bots ML, Visser GH, Bruinse HW. Emergency peripartum hysterectomy: a prospective study in The Netherlands. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2006 Feb 1;124(2):187-92.
3. Nagayama M, Watanabe Y, Okumura A, Amoh Y, Nakashita S, Dodo Y. Fast MR imaging in obstetrics. Radiographics. 2002 May;22(3):563-80.
4. Turner MJ. Uterine rupture. Best practice & research Clinical obstetrics & gynaecology. 2002 Feb 1;16(1):69-79.
5. Kainer F, Hasbargen U. Emergencies associated with pregnancy and delivery: peripartum hemorrhage. Deutsches Ärzteblatt International. 2008 Sep 12;105(37):629.
6. Chichester M. When your patient is from the obstetric department: postpartum hemorrhage and massive transfusion. Journal of PeriAnesthesia Nursing. 2005 Jun 1;20(3):167-76.
7. Baker Jr WF, Mansour J, Fontaine A. Post partum hemorrhage: Prevention, diagnosis, and management. Hematological Complications in Obstetrics, Pregnancy, and Gynecology. 2006:361.
8. Wade J, Pletsch PK, Morgan SW, Menting SA. Hysterectomy: what do women need and want to know?. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2000 Jan;29(1):33-42.
9. SUB-SAHARAN RC. INCREASING ACCESS TO SURGICAL SERVICES IN RESOURCE-CONSTRAINED SETTINGS IN SUB-SAHARAN AFRICA International meeting June 4 to June 8, 2007.
10. Banks A, Levy D. Life-threatening complications of pregnancy: key issues for anaesthetists. Current Anaesthesia & Critical Care. 2006 Jan 1;17(3-4):163-70.
11. Khanum Z, Lodhi SK. Emergency Obstetric Hysterectomy: a life saving procedure. Annals of King Edward Medical University. 2004;10(3).
12. Zelop CM, Harlow BL, Frigoletto Jr FD, Safon LE, Saltzman DH. Emergency peripartum hysterectomy. American journal of obstetrics and gynecology. 1993 May 1;168(5):1443-8.
13. Vázquez JA, Rivera GV, Higareda SH, Páez FG, Vega CC, Segura AP. Obstetric hysterectomy. Incidence, indications and complications. Ginecología y Obstetricia de México. 2008;76(03):156-60.
14. Habek D, Becareviç R. Emergency peripartum hysterectomy in a tertiary obstetric center: 8-year evaluation. Fetal Diagn Ther. 2007;22(2):139–42. doi:10.1159/000097114. PMID: 17139172.
15. Diab AE. Uterine ruptures in Yemen. Saudi medical journal. 2005 Feb 1;26(2):264-9.
16. Forna F, Miles AM, Jamieson DJ. Emergency peripartum hysterectomy: a comparison of cesarean and postpartum hysterectomy. American journal of obstetrics and gynecology. 2004 May 1;190(5):1440-4.
17. Christine C, Anthony S, Schönbeck Y, Visser GH. Congenital malformations among infants in breech position: a study of 1.4 million newborns. Term breech delivery in The Netherlands. 2006:81.
18. Bakshi S, Meyer BA. Indications for and outcomes of emergency peripartum hysterectomy. A five-year review. The Journal of reproductive medicine. 2000 Sep 1;45(9):733-7.
19. Kieser KE, Baskett TF. A 10-year population-based study of uterine rupture. Obstetrics & Gynecology. 2002 Oct 1;100(4):749-53.
20. Hsu YR, Kung FT, Roan CJ, Ou CY, Hsu TY. Emergency peripartum hysterectomy due to placenta previa/accreta: 10 years' experience. Taiwanese Journal of Obstetrics and Gynecology. 2004 Dec 1;43(4):206-10.
21. El-Jallad MF, Zayed F, Al-Rimawi HS. Emergency peripartum hysterectomy in Northern Jordan: indications and obstetric outcome (an 8-year review). Archives of gynecology and obstetrics. 2004 Dec;270(4):271-3.
22. Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan BK, Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section. Bmj. 2004 Jul 1;329(7456):19.
23. Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics & Gynecology. 2006 Jun 1;107(6):1226-32.